Friday, June 2, 2017
I've learned quite a bit being a hospice medical director. Covering dozens of new admissions a week has given me much insight into doctor prescribing habits. Often it is my job to decide with meds are necessary and covered by hospice, which are necessary but not covered by hospice, and which are useless.
Do you have any idea how many useless and often harmful meds our patients are on? I'm not just talking about end of life, but healthy patients to.
Can we talk multivitamins? Almost every patient I encounter is prescribed a multivitamin. Healthy, unhealthy, living, dying. When your in the grasps of stage five thousand and one lung cancer and your brain is riddled with mets, you have no business being on a multi. It's not going to help you. It's not going to provide that last bit of energy to overcome the calamitous collapse that is approaching rapidly. In fact, there is plenty of data to suggest multivitamins are harmful if not neutral at best. Even in healthy people.
How about Vitamin D? I swear to g-d, every patient I encounter is on some sort of D supplement. Never mind that the vast majority of medical evidence implies that supplementation is unhelpful in most disease processes. Yes, there is osteoporosis, but otherwise, it is a non starter.
Aricept in patients who don't walk, don't talk, and barely interact with the world around them? Again, started often because there is no other treatment, profound dementia patients are submitted to a host of side effects including diarrhea and syncope without the faintest glimpse of medical benefit.
Vitamin C, Vitamin E, Calcium?
How about statins in patients without a history of coronary disease with end stage-opathies and malignant cancers. Do we really think we are going to cut down on cardiac events in the fleeting few months that these patients have to live? Is there any data to support this? You better believe that these patients get myalgia and other side effects.
Antibiotics for foul smelling urine, screening urine cultures without symptoms, or agitation in an already agitated patient. It seems that treating non-utis has become the national past time of our healthcare system.
I could go on and on. Don't even get me started on antibacterials for non bacterial infections.
The point is, we are not being careful with our prescribing habits. We are not taking into consideration the wealth of evidence and data regarding some of these treatments.
And we are not being good advocates.
We are not shielding our patients from harm.
Posted by Jordan Grumet at 10:48 AM
Wednesday, May 17, 2017
It starts with birth. The awareness of our own unique helplessness is overwhelming. We are a slave to our children's genetics, environment, and wholly uncontrollable luck. We skitter to command a million details to defray the constant anxiety of that which can't be governed. We worry, lose sleep, and panic till the day we feebly shrug our shoulders and accept. Then we defer to faith. Because faith is air, and we must breathe.
As my daughter has grown, that faith has transferred from the intangible nebulous, to the burgeoning humanoid sprouting at my feet. A far more comfortable leap, a sense of control sets in. As parents, we can lead by example, teach, shape, and mold. Destiny has temporarily released her grasp. My daughter can learn not to climb on the hot stove, to look both ways before crossing, to stop, drop, and roll.
So you would think it is the consequential stuff that I struggle with, but often the ephemera nips just as gratingly at my heels.
A few weeks ago, my daughter informed us that she wanted to perform in the annual school talent show. Each year, we battle to convince her to play the violin, something she actually holds a sprinkling of talent for. Sometimes we win, others we lose.
This year she decided that she would perform a solo dance routine, and no matter how much I tried, she could not be dissuaded. My anxiety rose as I pondered our weekend dance performances in the family room. Rhythm, it turns out, may not be at the top of my daughter's otherwise many talents.
Much discussion was had, videos were You Tubed, lists were made. And two days before the performance, it was clear that her best option was to free style the whole routine. My heart raced as I pondered her up on that stage in front of hundreds of people, awkward, and embarrassed. This has been a hard year for her at school, and the last thing I wanted was for it to end in shame.
My daughter, however, was implacable. She repeated over and over again:
I got this!
The day of the event, she pushed us out of the way and applied her own makeup. I marveled at the mix of eye liner and lipstick (something we otherwise would never let our daughter wear). She looked fierce.
When she took the stage at the tail end of the show after fifty other acts, I stood nervously with camera in hand. She awaited patiently through three attempts to queue her music correctly. I could no longer control the fluttering in my chest.
I keenly felt at that moment something, in retrospect, I have always known.
That I will follow this girl with all my heart down whichever path she leads. And I will have faith even though the journey will often be awkward and painful and sometimes...
Sometimes joyful and wondrous.
Posted by Jordan Grumet at 10:41 AM
Friday, May 5, 2017
These thoughts jostled through my mind this morning as I pulled into the hospital parking lot. A recent momentous decision, I surrendered my privileges at this hospital and started using the hospitalists. It had all become too hard. The inane compliance issues with the new EMR. The ER attendings admitting my patients without calling me. The slew of protocols, documents, and attestations at this institution recently became particularly onerous. The administration was pushing out the primary physicians with the indignation of a million not so subtle pinpricks.
I was making a courtesy visit. I had asked the Emergency Room physician to have the hospitalist call me the night before. I knew this patient exceedingly well over the years, and had a good impression of what had happened. I was unable to relay this information, however, because I never got a phone call.
I didn't agree with the diagnosis or treatment plan. The admitting hospitalist was no longer available and the nursing staff had no idea who to call. I carefully documented my knowledge of the patients past medical history, exam, and my thoughts in a progress note. I also left my mobile number and begged the rounding physician to call me. I am not hopeful. Eventually, after much searching and paging, I will likely reach the physician by the end of the day. Que sera, sera.
This hospital is in the midst of a major rebuild, and part of the process is a new entrance to the expressway adjacent to the parking lot. The beauty of this new pathway is that following a few careening turns, the entrance ramp is a straight shot for a few hundred feet.
This morning, I came to a full stop after those turns, and waited for the cars on the expressway to pass at 60 mph. I put all four windows down. Then I put the pedal to the metal.
10, 30, 50, 70mph, I sped past all the cars ahead of me. The wind blowing into the car and smacking me in the face. Power, speed, freedom, joy!
Eventually I merged left and began the process of applying the brakes. I was coming up quickly on a series of cars driving at more conventional speeds.
The fun is over. It couldn't last forever.
It seems it's no longer our patients that we answer to.
Because I've been told, in no uncertain terms, it's time to stop bucking the system.
And get back into my appointed lane.
Posted by Jordan Grumet at 8:28 AM
Saturday, April 1, 2017
As Hannah's granddaughter clutched at her skeletal fingers, the blanket fell to the side revealing the faded serial numbers on her forearm. The family gathered, yet again, to say goodbye. This time her acrid breath had lost humidity, her respirations dry and raspy, the extremities mottled with a bluish tinge.
Death had visited the neighborhood before. Lounged in the parlor. Nibbled on crackers and tea. But letting go was not so easy. Sure the signs were there. There were the bouts of unconsciousness lasting days. The hours of irregular breathing with long gaps. The clutching of chest and recitation of prayer. All followed by merciless, unrelenting recovery.
Hannah wanted to die. At least that is what she told the doctors. She sang it in her sleep and whispered to the hallucinations that pranced on her pillow. She refused medications. She spurned nourishment. She pulled at the tube thoughtlessly plunged into her abdomen a few hospitalizations prior. She hissed at the Rabbi as he entered her room.
Why won't you take me?
They said she was a survivor. A code they used in order to avoid talking about dark things. Guilty things. She was forever marked by the fact that she didn't succumb. She didn't die. She was scarred somewhere deeper, more profound, than the ugly thing on her forearm. She was marred by persistence.
Most of her family died decades ago during the war. A whole lineage erased. And yet she persisted. Her colon removed, her brain stroked, her heart fibrosed. And yet she persisted. The years passed, friends and lovers gone, a child or two perished. And yet she persisted.
Persistence had entwined her DNA, calcified her bones, and cascaded past blood cells forever traveling in circles.
Her body was failing, but her spirit couldn't let go.
No matter how much she begged and pleaded.
It didn't know how.
Five Moments, now available on Amazon.
Also available, I Am Your Doctor: and This is My Humble Opinion.
Posted by Jordan Grumet at 1:37 PM
Friday, March 17, 2017
It was not so much the words as the overall tone of the interaction. The doctor-patient relationship had been generally affable. There was the usual exchange of pleasantries over the years. Questions about family, children and grandchildren. It was a good relationship. Until Harvey got sick, that is.
Originally there was weight loss and fatigue. The initial physical exam and slew of testing showed nothing but a frail, cachectic, middle aged man. A few cat scans later and he was in the oncologist's office discussing chemotherapy. A regimen was decided on, and therapy began the next day.
Therapy was hard. Nausea. Retching. More weight loss. Far from feeling better or cured, Harvey could feel the clothes slipping from his emaciated body. It was as if life itself was drip dripping away as the chemo bulldozed into his broken veins. And this pissed Harvey off.
He lashed his family. He cursed his friends. He spun into a whirlwind of the most resistant depression. A depression, his therapist would later tell me, whose only salve was anger. While the anger allowed him to carry on, often he left those around him scorched.
His doctors were no exception. We often spent half of each visit withstanding abuse before getting down to the business of the appointment. He blamed us for the cancer. He blamed us for the lousy response. He blamed us for the side effects of his abysmal treatment.
So when I walked into the hospital room to tell him the scans showed his latest chemotherapy had failed to stem the red tide of death, I have to admit that I had already somewhat detached. How could I not? Although he was fairly lathered by the results, it was the mentioning of hospice that finally led to my expulsion. His wife ran after me with tears in her eyes. I'm quite certain that she paid dearly for her kind act of decorum.
Harvey died shortly thereafter.
I am prone to remember the pleasantries Harvey and I enjoyed before his health deteriorated. I am neither disturbed nor saddened by the anger. I cannot even say that I would not have been the same way if I had been lying in his hospital bed.
What surprises me, in retrospect, is how little he affected me. How his anger didn't penetrate the hardened shell.
Over my career I have been yelled at, cursed, blamed, hugged, and even loved by my patients.
And like the poor life force oozing out of Harvey's beleaguered body, it drip drips down my back.
And into a forgotten puddle on the ground.
My new book: Five Moments, now available on Amazon.
Posted by Jordan Grumet at 8:32 AM
Sunday, March 12, 2017
“Dad . . . you can let go now.”
Thomas heard his daughter’s voice from a distance. It awakened him from his reverie. He relived those five moments of life and took their lessons seriously.
Rejoice in the ordinary as if you were a child seeing everything for the first time.
Unconditional love can lift you up.
Forgive yourself over and over again.
No matter how much we deny it, we are who we are.
Some of the most difficult battles are those in which we choose not to fight.
Thomas opened his eyes and smiled. He looked at the faces of his family before him. After all these years he finally got it. He understood the meaning of existence that eluded him till now.
Eternity . . . Immortality . . .
His family was now joined by numerous others. Thomas’s friends and colleagues, his patients and students, even the man he once gave a five-dollar bill to on the street. They were all there. He gave a part of himself to each of these people. And each of them had given a part of themselves to others. There were thousands, if not millions, of people in the room with Thomas.
His life had meaning. Like a rock falling into a pond, his goodness made a small splash with the people around him. But the waves from the rock rippled throughout the pond. Thomas would live forever. Parts of him were dispersed into the world. And those parts would live and thrive. Thomas’s body was dying but his soul was strong. He felt oneness with his fellow man.
For a moment Thomas thought if he just had enough strength he could share this beauty with his family. But then he realized this was not the sort of thing someone could teach. Each person had to experience it himself.
Isabella’s word’s came back to him as he drifted off.He remembered sitting on the kitchen floor with his daughter and granddaughter the day she almost choked to death.
“See, Dad? It wasn’t all in vain.”
Thomas experienced one last thing before he died.A cool sensation started at the back of his head and washed over his cheeks, shoulders, body, and into his toes. With pure joy, he recognized this as the first sensation he felt upon exiting the birth canal.
Beginning and End. Birth and Death. They were all intermingled in this beautiful dance called Life.
Thomas’s heart stopped.
Posted by Jordan Grumet at 5:54 PM
Monday, March 6, 2017
Be assured that this will pass. Life has changed incomprehensibly in a fraction of a moment. It will take a few more moments for your psyche to advance accordingly. This is not disconnection. This is not denial. It's shock.
Grief will not be far behind. Overwhelming, discoloring, disjointed grief. Some will try to ignore it. Others will wallow. How you manage this grief says more about who you are and less about the gravity of the loss. There is no correct way to map this journey. We each travel this road separately.
My gentle advice to you dear traveler, is remember that separate does not mean alone. Others will not feel what you are feeling, but that does not prohibit sharing parts of your journey. The most arduous, at least. Surround yourself with people and things. Even if they have lost your interest. Even if they have lost meaning.
Interest and meaning return. The sun rises and falls. You will not break.
By far, the greatest danger lies ahead. In the days and weeks and years. You may be plagued by a demon so fastidious it will devour your hours, conscious and otherwise. It will haunt long nights and merciless days. It will cause the ground to shake relentlessly under your feet, knocking you off balance.
I'm talking of guilt.
You will feel guilty for not spending enough time, or spending too much. For not calling the nurse right away, or calling too quickly. For pushing the morphine that last time, or withholding it. Even the quiet and peaceful deaths end here. It is loves last grappling with earth-shattering loss. We are not programmed to let go of that which we cannot control.
And we can't control death. So we feel guilt.
This guilt will plague you. It will turn grieving from a process to a permanent state.
Don't let it. Your loved one died because it was time. Nothing you did would have changed that.
Let this forgiveness be one last act to honor the dying.
If you like this post, please order my new book of short fiction, Five Moments.
Posted by Jordan Grumet at 9:10 AM